Basic Information
| Provider Information | |||||||||
| NPI: | 1275742728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKERT | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 MACK ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137514222 | ||||||||
| FaxNumber: | 5138243023 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 MACK ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137514222 | ||||||||
| FaxNumber: | 5138243023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35083273E | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2959679 | 05 | OH | MEDICAID |